HomeMy WebLinkAbout040-1276-30-000 (2)
vasrnasm UCUa'hncn: c'CC~ -eae PRIVATE SEWAGE SYSTEM t.cumv. St. Croix
Sa'ch and Bailding Div ,nr
INSPECTION REPORT -mita'v Permit Nc
GENERAL INFORMATION IAFTACI I TO PERMIT] SAN-2017-096
Sta:c Plan ID NC
Fersc'na nfnrnatinr ^l p•o'nuc may be ~sed'a ucnrda-, Par,,,,, 'PUVacy La, s. ! b A it::.wl
Permi' Hnlcers Name i;ily Village Tovrrship Parcel Tax Ns
RYAN CART TOWN OF TROY 040-1276-30-000
-ST RM F.fr I-sr, RM Flee BM Deser PFc- entonr I,,,. darge,Miap hu
/60 fo, Lit-(XL 08.28.19.1535
TANK INFORMATION ELEVATION DATA
YPF MANUFAC IJRi-R t A:y CAPACITY STATION PIS HI FS ELEV.
Septic I Benchmark
e G ~~.p t/Z 7 1611• y /dv f
Dosing G O JW ~O 1 n¢. BM~I Z c~/3 ' S 1
Aerei rvO ~
Bing Sevier
r, I L- I Holding SUHt Inlet
SUHt Outlet
TANK SETBACK INFORMATION
TANK TO , L6 WELL BLDG Ai- hrtaf:e ROAD IN Iniet
Seph:: Z2 36 [A Bottom Ig• D T3, C,
Dosing 4 I~ HeaderWan.
r-
Aeration D st. Pipe
Hording Bot. System' v b
PUMP/SIPHON INFORMATION final Glade
Manufacturer Demand St Cover zi S l
zoeA~ (;I'M
kludel Number
TDH Lift i ric ion t oss N Svstem I lea fl TDH(~J it
Foreemain Lenylh Dia. D t le. Vie. fc~
SOIL ABSORPTION SYSTEM 13.1 S +-'q' 12.5
BED,TRENCH Wiidtr _un~tn Nr UI i rone'res PIT DIMENSIONS N.,. pl Piss Psd=_ Ga I ig.:m )~p'n
DIMENSIONS ~
SETBACK SYSII TO Pil BLDG WEII I.AKE!STREAId LEACHING lAandtaoturer.
INFORMATION CHAMDFR OR
Type O' Syste"
UNIT Wodc Nurnba.
DISTRIBUTION SYSTEM
Ib,nreOManilUld J.sir nut un Ho
e
x •iole .,i r le Si "n V • ; Ar nl ' %e
,iFeiv aJ
myth Dia__ . cnr;0i D.. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
DP.nm Over I Dent- Over x,. (:C•Idl' nl $E2dedf$UdCeC lY !.1lIlCfred
Bedrilencir Center U.'Xircnch Etlges. Tupsa
Yes N;. Yes Nn
COMMENTS: (include code discrexncies persons Dritsenl. etC.i Inspectlor #1: Inspcetmn u?
Location: 392 1 M G rr /
~ 1 t ~ ~ v}QJ
I.; All BM Description =
2. i Bldg sewer length = 1A- 5,6
- amount of ::over = /t ~
3 e ri~]1C).( 1)L
Plan revision Required? Yes F No Zz
Use other side for additional Inlormation L (Q 0 J /rte
Dale - Irsz r. '.a1u':: Ce7 ho
SRD-6' 11) IR 3N.'}
A&- aluf-7- o96
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
Ir acco-c %vdh Chapert 12 St . Crob urty Sanitnnr Orcinvrc~ PLANNING & ZONING DEPARTMENT
~tf ! litersonal mforrna:ion you provide may be used for seco.ndarv pu-po~,v, ST. CROIX COUNTY GOVERNMENT CENTER
[Pnva y rn.v S. 15 ,:411 {jml] 1101 Carmichael Road
Hudson, WI 540167710
_ I. 151386-4680 Fax:7'5!3864686
Attach) complete plans for t " Inches n sr.-e.
^ aortal Pemut K ,r
r>
opme .5,AAJ 'Z04 -1 09 1-0
1. App - MIOO - Please P II Information Location:
Property ~~mner Nark 4 _ -
1i4 - 14 . Sec
ti PJ N, R ZC1 t,) E tor) VJ
Property Owners Mailing doress Lot N' Block Nur+toer
~
Z2 C
O1~ C -
City. State Zip Code Phone Numer Sub Iwslon Name or CSM Number
n
f' '1
v tit L
II Type of Building: (check one) [3:ry ❑ Ilage owr o'
yam- ' or 2 Family Dwelling - No of Bcar;:pms.
❑ Pubho --ummcrciat {oescuo•_ uses (4L Y`O
❑ State-p'.vn?d Nearest Road
IL Type of Permit: iCheck only one be) 0~.1 line A. ChvCK cox cn Lne B P applicable) 31d 0n,, k'- C
Farce. Tax Numbersi p t{
11 E] Repar ? Recomerean 3 CINan-piurrrinq 4. CjReiuvenation od. Mfr. 19. IS05
A) 0q0 jJl-76- 3C
Sail)"
B) r'ermit Number Date Issued
1 4 State Sanitary Dellilt was viev10J51y' issued -
IV. pe of POWT System: (Check all that apply) 1 ~iL
Non-pressurized In ground ❑ PAounc L 74 In suitable spi r1 talnund s i`4 n. sl.itab'.^_ soil ❑ Mound ADO
❑ Sand Fillet ❑ Cunst•uclec Waiand Peat FIITer ❑ Drip Line
%F ❑ Hoioing Tark ] S role Pass ❑ Other
At-1rarl- ❑ Aerobic Treatment UnC El kvc"uxatrr,
V. Dispersal/Treatment a Information:
Desigr Flow igpol 2. Dispersal Area a Dispersal Area 4 Sm Apphcahnn Rate _ ?clcuiauon Rate 6 Svs:e'n Fevation - Final ;;tare
Requhed Proposed IGxs.lcav'sq ft JJ'r imchj Elevation
VI. Tank Information Caoaicty in Gallon- -ota 9 0' Manutacsurer Prefab Site Cor- Steel Fiber. Plastic
Ne'.v Fxishrc Ga113ns. Tanks Goncrele slructed glass
Tanks Tanks
ZOO ❑ ❑ ❑
III VI I, W', e-oAAA-
VII. Responsibility Statement
I the undersigned. assume •esDorsibility for repaiUreconnenaipn?re;uvenali0rt:ins:allation of non piuncing for the POVJTS shown on the attached plans A
license snot required for :enahtl repair or the installation of non piurlbino sanilaCor system.
Plumbers Name Iprintl Plurri Signature Inc, stamos% e ry 1`11~411PRS No Business Phone Number
- a :r.1 T v1w- ~iC' -71S-76 o- S~
Plumbers A Jress f Street, City. Stale, Z F Coot'
G ! O >
f'n wr 5
VIII. County Use Only
Disapprovec Sani;ay Permit Fee Da , Iss ed issuer . _em Signature . stam
Appmved Owner Giv, nia v 111
rauor or IX. Conditi9 asons for Disapproval:
6~ n~ $ Z
t, pqplwl lark ark, arllutmltW q►d -~6 to. &-14- dT
u:spec , cell tn" ell 9111-AWY, 8~ ' r,lf ~n 9L
D kw by ohimlaw.
ate per 1lar.agarnervnlttat:tw t:l~nft Yxd ~a w,~ i/.L./k~. G • o
Rev. 6/05
EX~=)~i~~l radC /Zfu/.'
1371
3 ?-Z Oma /L It
Stj~SE%''/, Sec., B"T ?BK.
EX/3E1.r Cu,'esar Cuic /tte \ cc?/
~s~o~//f.sy.E:c.Ec~K'y'_ f~ocs~~i v •d~ /~c~'~oyru-/»C,-3o-crt,
2Pbc! fi-&z e///P+ E Ctu: (14(✓c /:e,~r acles
Ce/L r~Lthccn.uc4td
fic~csedWrc>erC'n,c/-c(e nn ---•by:n~fs+//oLI;0, a{'
/.N~S'.~~fiu rr,:f9Cfw.n 6/r' !'00:~ pli✓c/s,-ply ✓4.Ae.
a ~
• V
J -r,1 "~Stcr -71
Q p
d.,,K i w f/- .6.1,7 : U rn ~9'
~ r, ~ eusE.~ ! 5,-,46~- J, _ 96.75
1 a- (I •'V•r_lo:~ k<s.:li.tcc casp%.P, ck/;✓ewcr
1PI, -
L PonnJJ~,
Exae C--Ie.-
E/err = /ov:en
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P.J.G.\ 4 Znl; rFir.L'✓e .S,.. fi,ce
' Force Man Pi<J-97. vo,
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ST. CROIX COUNTY
SEPTIC TANK MAINITNANCF. AGRFF,MENT
AND
0%VNERSHIP CERTIFICATION FORM
Ocaner HuyerRyan Cad
Mailing Address _392 Omaha Crt, Hudson, WI 54016
Property Address Same
(Vcrificianm required from Planning Zoning Depanment for new instruction.)
1 276-30-000
City/State Parcel Identification Number 040-11,276-30-000 LEGAL DESCRIPTION
Property Localion SE ,,r SE S,, , Sec. 8 T 28 N R 19 W, Town of Troy
Subdivision Plat: Eagle Bluff - - - • Lt,t # 3 .
Certified Survey Map# Na Volume Na Page# Na
Warranty Deed # (before 2007)Volume , Page #
Spec house Oyes[Zlno Lot lines idcntitiable Oyesono
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
I mpmpcr use and mai atenuncc of your septic system could result in its premature failure to handle wastes- Proper
rnanurnanec consists of pumping out the septic tank every three years or sooner, if needed, by a liccmed pumper. What you put into
the system can anect the function of lhc. septic tank as a Vestment stage in the waste disposal system. (honer maintenance
rcaponsibilities are specified in §SPS. 38152(.1) and in Chapter 12 - St. Croix County Sanitary ordinance.
the property owmcv agrees to submit to tit, Croix County Planning & Zoning Department a certification form, signed by the
(o ncrar d by it maser plumber, )oumevman plumber, restricted pfuntbet or a licensed pumper veritying that (1) Ore on-site
wastewater disposal system is in proper operating condition an&rir (2) after inspection and pumping (if necessary), die septic lark is
less than lit full of sludge.
];we, the undersigned have read the above requirements and agree to maintain die private sewage disposal system with the
.standards set troth, herein, as set by die Department of Safety And Prufmionai Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic systern has been maintained must be completed and returned to the tit. Croix
Cowry Planning & /oiling Department within 30 days of the three year expiration date.
Vwc certify that all statements on this form are true to the best of my/our knowledge. roc atwarcthe owner(s) of Ote
property described above, by virtue of a warranty deed ccordcJ in Register of Deeds Offcc.
Number of bedrooms
-4~~ SIGNATURE OF APPLICANT(S) DATE.
***Any information (hilt is misrepresented may result in the sanitary pcrmil being revoked by the Planning & Zoning Department.
Include with this application a recorded wurranty decd from the Register of Devils Oft-ice and a copy of the certified survey map if
reference is made in the warranty decd.
(REV. 00112)
9oFY/